The Patient with Severe Hair Loss: Planning and Decision-Making

24 The Patient with Severe Hair Loss: Planning and Decision-Making

Michael L. Beehner

Summary

This chapter deals with a surgical philosophy for treating the male patient with a very large area of alopecia. There are two groups of men in whom this can be applied to: those who already have a huge area of balding and the younger man whose future balding pattern is unknown or who already has warning signs that he will join this first group later in life. Three different forelock patterns are discussed here: The “shield” forelock, the “oval” forelock, and the partial “hemi-oval” forelock. There are three design concepts that apply to all three. They are:

1.Exclude the posterior vertex region from the area to be transplanted (with rare exceptions).

2.Not being overly aggressive in bringing the front hairline anteriorly or in filling the frontotemporal gulf region.

3.A front-central region with maximal density, which frames the face, and a decreasing gradient of density of small grafts to blur the bald scalp lateral and posterior to the central forelock body.

Keywords: frontal forelock advanced hair loss Norwood VII pattern shield forelock pattern oval forelock pattern hemi-oval forelock pattern alopecia hairline patterns

Key Points

•Virtually all men with balding can be transplanted if a forelock pattern is used.

•Lowered expectations are needed.

•The key is to capture a natural stage of balding that exists in nature and create it using transplants for the patient.

24.1 Introduction

A few facts are indisputable in hair restoration surgery: One is that, for most men with hereditary hair loss, the process is a progressive one throughout their adult lives. Another is that our most important goal for most patients is “framing the face” in the upper forehead region. Fortunately, most of them have sufficient donor hair and a reasonably sized recipient area, such that we are able to transplant from one fringe border to the other with fairly good density in the frontal and midscalp zones. However, some have a large disparity between the small amount of donor hair available and the recipient area. For this group of patients, it is best to have an artistic approach that fulfills a number of conditions: First, it should frame the face and give a reasonably “full” appearance from the front view. Second, it should appear natural, in that it should imitate a natural stage of hair loss that many men pass through as they age. The patterns described are helpful for the “very bald,” and are also important to use for those younger patients who present with early hair loss and have warning signs in their history and examination that they might progress to a Norwood VII pattern. For these individuals, it is necessary to use a conservative approach that will be compatible with the “worst case scenario” that could develop. It is the responsibility of the hair surgeon to communicate to the patient why a conservative approach is in their best interest. The hope is that the expectations of the surgeon and patient match up and that there is a bond of trust between them.

The patterns allow hair restoration surgeons to use a limited amount of donor hair to treat a very large balding area and bring about a natural-appearing framing of the face, which will continue to look natural as the patient ages.1

24.2 When

So, when should the hair transplant surgeon use one of these “forelock” patterns? The answer is whenever the surgeon feels there is not enough donor hair to adequately fill the frontal and midscalp zones with hair that extends from one lateral fringe to the other. With the forelock approach, one seemingly is able to make “less” appear “more.” All of the outlying sparser zones play off of the central density of the forelock’s “core” in the front-central region. In the gap area between the forelock and the lateral fringe, the goal is to create a “mirror image” effect visually. This area is transplanted somewhat sparser than the forelock body, with the goal of blurring that space and avoiding the creation of a bald “alley.” With this design concept, the rear vertex is generally not transplanted and the frontotemporal recessions are not aggressively filled in or brought forward. This allows the surgeon to use the great majority of the available donor hair in the forelock area for maximal visual effect.²

The forelock transplant pattern is for the middle-aged to older gentleman with a neatly defined advanced Norwood VI or VII hair loss pattern. It is also for male patients with early onset of male pattern baldness and those with retained hair that is likely to be lost in future. Factors that should warrant a more conservative approach, especially for the male patient in his 20s or 30s, would be family history of Norwood VII patterns among male relatives, the presence of “whisker hair” around the ears, or indistinct fringe zones with evidence of miniaturization of some of the follicles. The author’s unofficial cut-off age for transplanting young males is 23, but on rare occasion a 21- or 22-year-old can be transplanted in the central aspect of the frontal zone. It is important, in evaluating younger males with hair loss, to rule out the DUPA pattern (diffuse un-patterned alopecia), which is characterized by a widespread pattern of thinning and miniaturization throughout both the recipient and the donor areas. These men are almost never good candidates for transplantation, as a donor scar or follicular unit excision “dots” would both show through eventually and much of the hair transplanted to the top will most likely eventually be lost.

One has two theoretical choices in transplanting such a patient with a large area of alopecia and limited donor: One choice, not recommended, would be to spread the available donor grafts in a diffuse, homogenous distribution over the entire balding scalp. The second choice is to limit the distribution of the available grafts to the front 60 to 70% of the balding area and to use gradients of density to help create a relatively dense front-central zone, from which hairs in decreasing density are placed laterally and posteriorly. The first choice is a poor choice, because it does not frame the face and will almost always result in a see-through look. The second choice allows the hair surgeon to use the precious donor hairs in such a way that you make a difference in a limited area and, in doing so, transform the overall appearance of the patient (Fig. 24.1 and Fig. 24.2).